Group items tagged

Canada has catching up to do compared to other OECD countries. Canadians have difficulty accessing primary care, particularly after hours and on weekends, and are more likely to use emergency rooms.

only 32 per cent of Canadians had access to more than one primary health care provider

In Peterborough, Ontario, for example, a region-wide shift to team-based care dropped emergency department visits by 15,000 patients annually and gave 17,000 more access to primary health care.

We believe that jurisdictions are now turning the corner on primary health care

Sustained federal funding and strong jurisdictional direction will be critical to ensuring that we can accelerate the update of electronic health records across the country.

The creation of a national pharmaceutical strategy was a critical part of the 10-year plan. In 2011, today, unfortunately, progress is slow.

Your committee has produced landmark reports on the importance of determinants of health and whole-of- government approaches. Likewise, the Health Council of Canada recently issued a report on taking a whole-of- government approach to health promotion.

there have also been improvements on our capacity to collect, interpret and use health information

Leading up to the next review, governments need to focus on health human resources planning, expanding and integrating home care, improved public reporting, and a continued focus on quality across the entire system.

John Wright, President and CEO, Canadian Institute for Health Information

the Canada Health Act

Since 2008, rather than repeat annual reporting on the whole, the Health Council has delved into specific topic areas under the 2003 accord and the 10-year plan to provide a more thorough analysis and reporting.

We have looked at issues around pharmaceuticals, primary health care and wait times. Currently, we are looking at the issues around home care.

John Abbott, Chief Executive Officer, Health Council of Canada

I have been a practicing physician for 23 years and a CEO for 10 years, and I would say, probably since 2005, people have been starting to get their heads around the fact that this is not sustainable and it is not good quality.

Much of the data you hear today is probably 18 months to two years old. It is aggregate data and it is looking at high levels. We need to get down to the health service provider level.

The strength of our ability to report is on the data that CIHI and Stats Canada has available, what the research community has completed and what the provinces, territories and Health Canada can provide to us.

We have a very good working relationship with the jurisdictions, and that has improved over time.

One of the strengths in the country is that at the provincial level we are seeing these quality councils taking on significant roles in their jurisdictions.

As I indicated in my remarks, dispute avoidance activity occurs all the time. That is the daily activity of the Canada Health Act division. We are constantly in communication with provinces and territories on issues that come to our attention. They may be raised by the province or territory, they may be raised in the form of a letter to the minister and they may be raised through the media. There are all kinds of occasions where issues come to our attention. As per our normal practice, that leads to a quite extensive interaction with the province or territory concerned. The dispute avoidance part is basically our daily work. There has never actually been a formal panel convened that has led to a report.

each year in the Canada Health Act annual report, is a report on deductions that have been made from the Canada Health Transfer payments to provinces in respect of the conditions, particularly those conditions related to extra billing and user fees set out in the act. That is an ongoing activity.

there has been progress. In some cases, there has been much more than in others.

How many government programs have been created as a result of the accord?

The other data set is on bypass surgery that is collected differently in Quebec. We have made great strides collectively, including Quebec, in developing the databases, but it takes longer because of the nature and the way in which they administer their systems.

I am a director of the foundation of St. Michael's Hospital in Toronto

Not everyone needs to have a family doctor; they need access to a family health team.

The family doctors in our hospital feel like second-class citizens, and they should not. Unfortunately, although 25 years ago the family doctor was everything to everybody, today family doctors are being pushed into more of a triage role, and they are losing their ability.

The problem is that the family doctor is doing everything for everybody, and probably most of their work is on the social end as opposed to diagnostics.

At a time when all our emergency departments are facing 15,000 increases annually, Peterborough has gone down 15,000, so people can learn from that experience.

I have to be able to reach my doctor by phone.

They are busy doing all of the other things that, in my mind, can be done well by a team.

That is right.

if we are to move the yardsticks on improvement, sustainability and quality, we need that alignment right from the federal government to the provincial government to the front line providers and to the health service providers to say, "We will do this."

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

with actual strategies, investments, tactics, targets and outcomes around a number of things

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

which may not always be the most cost effective and have the better outcome.

We are looking at developing quality indicators that are not old data so that we can turn the results around within a month.

Senator Eaton

There are different types of benchmarks. For example, there is an evidence-based benchmark, which is a research of the academic literature where evidence prevails and a benchmark is established.

The provinces and territories reported on that in December 2005. They could not find one for MRIs or CT scans. Another type of benchmark coming from the medical community might be a consensus-based benchmark.

universal screening

A year and a half later, we did an evaluation based on the data. Increased costs were $400 per patient — $1 million in my hospital. There was no reduction in outbreaks and no measurable effect.

A thorough research of the literature simply found that there are no evidence-based benchmarks for CT scans, MRIs or PET scans.

The evidence is pretty clear for the high acuity; however, for the lower acuity, I do not think we know what a reasonable wait time is

If you are told by an orthopaedic surgeon that there is a 99.5 per cent chance that that lump is not cancer, and the only way you will know for sure is through an MRI, how long will you wait for that?

colorectal screening

the next time they do the statistics, there will be a tremendous improvement, because there is a federal-provincial cancer care and front-line provider

adverse drug effects

over-prescribing

There are no drugs without a risk, but the benefits far outweigh the risks in most cases.

catastrophic drug coverage

a patchwork across the country

with respect to wait times

The interesting thing about Saskatchewan is that, on a three-year trending basis, it is showing positive improvement in each of the areas. It would be fair to say that Saskatchewan was a bit behind some of the other jurisdictions around 2004, but the trending data — and this will come out later this month — shows Saskatchewan making strides in all the areas.

In terms of the accord itself, the additional funds that were part of the accord for wait-times reduction were welcomed by all jurisdictions and resulted in improvements in wait times, certainly within the five areas that were identified as well as in other surgical areas.

We are working with the First Nations, Statistics Canada, and others to see what we can do in the future about identifiers.

Have we made progress?

I do not think we have the data to accurately answer the question. We can talk about proxies for data and proxies for outcome: Is it high on the government's agenda? Is it a directive? Is there alignment between the provincial government and the local health service providers? Is it a priority? Is it an act of legislation? The best way to answer, in my opinion, is that because of the accord, a lot of attention and focus has been put on trying to achieve it, or at least understanding that we need to achieve it. A lot of building blocks are being put in place. I cannot tell you exactly, but I can give you snippets of where it is happening. The Excellent Care For All Act in Ontario is the ultimate building block. The notion is that everyone, from the federal, to the provincial government, to the health service providers and to the CMA has rallied around a better health system. We are not far from giving you hard data which will show that we have moved yardsticks and that the quality is improving. For the most part, hundreds of thousands more Canadians have had at least one of the big five procedures since the accord. I cannot tell you if the outcomes were all good. However, volumes are up. Over the last six years, everybody has rallied around a focal point.

The transfer money is a huge sum. The provinces and territories are using the funds to roll out their programs and as they best see fit. To what extent are the provinces and territories accountable to not just the federal government but also Canadians in terms of how effectively they are using that money? In the accord, is there an opportunity to strengthen the accountability piece so that we can ensure that the progress is clear?

In health care, the good news is that you do not have to incent people to do anything. I do not know of any professionals more competitive than doctors or executives more competitive than executives of hospitals. Give us the data on how we are performing; make sure it is accurate, reliable, and reflective, and we will move mountains to jump over the next guy.

There have been tremendous developments in data collection. The accord played a key role in that, around wait times and other forms of data such as historic, home care, long term care and drug data that are comparable across the country. Without question, there are gaps. It is CIHI's job to fill in those gaps as resources permit.

The Health Council of Canada will give you the data as we get it from the service providers. There are many building blocks right now and not a lot of substance.

send him or her to the States

Are you including in the data the percentage of people who are getting their work done elsewhere and paying for it?

When we started to collect wait time data years back, we looked at the possibility of getting that number. It is difficult to do that in a survey sampling the population. It is, in fact, quite rare that that happens.

Do we have a leader in charge of this health accord? Do we have a business plan that is reviewed quarterly and weekly so that we are sure that the things we want worked on are being worked on? Is somebody in charge of the coordination of it in a proper fashion?

Dr. Kitts: We are without a leader.

Mr. Abbott: Governments came together and laid out a plan. That was good. Then they identified having a pharmaceutical strategy or a series of commitments to move forward. The system was working together. When the ministers and governments are joined, progress is made. When that starts to dissipate for whatever reason, then we are 14 individual organization systems, moving at our own pace.

You need a business plan to get there. I do not know how you do it any other way. You can have ideas, visions and things in place but how do you get there? You need somebody to manage it. Dr. Kitts: I think you have hit the nail on the head.

The Chair: If we had one company, we would not have needed an accord. However, we have 14 companies.

There was an objective of ensuring that 50 per cent of Canadians have 24/7 access to multidisciplinary teams by 2010. Dr. Kitts, in your submission in 2009, you talked about it being at 32 per cent.

there has been a tremendous focus for Ontario on creating family health teams, which are multidisciplinary primary health care teams. I believe that is the case in the other jurisdictions.

The primary health care teams, family health care teams, and inter-professional practice are all essentially talking about the same thing. We are seeing a lot of progress. Canadian Health Services Research Foundation is doing a lot of work in this area to help the various systems to embrace it and move forward.

The question then came up about whether 50 per cent of the population is the appropriate target

If you see, for instance, what the Ontario government promotes in terms of needing access, they give quite a comprehensive list of points of entry for service. Therefore, in terms of actual service, we are seeing that points of service have increased.

The key thing is how to get alignment from this accord in the jurisdictions, the agencies, the frontline health service providers and the docs. If you get that alignment, amazing things will happen. Right now, every one of those key stakeholders can opt out. They should not be allowed to opt out.

the national pharmaceutical strategy

in your presentation to us today, Dr. Kitts, you said it has stalled. I have read that costing was done and a few minor things have been achieved, but really nothing is coming forward.

The pharmacists' role in health care was good. Procurement and tendering are all good. However, I am not sure if it will positively impact the person on the front line who is paying for their drugs.

The national pharmaceutical strategy had identified costing around drugs and generics as an issue they wanted to tackle. Subsequently, Ontario tackled it and then other provinces followed suit. The question to ask is: Knowing that was an issue up front, why would not they, could not they, should not they have acted together sooner? That was the promise of the national pharmaceutical strategy, or NPS. I would say it was an opportunity lost, but I do not think it is lost forever.

thanks to predictable and escalating funding over the first seven years of the plan

however, there are, unfortunately, pockets of inattention and/or mediocrity as well

Six areas, in fact, were identified by CHA

funding matters; health human resources; pharmacare; wellness, identified as health promotion and illness and disease prevention; continuing care; and leadership at the political, governance and executive levels

The focus of this 10-year plan has been on access. CHA would posit that it is at this juncture, the focus must be on quality and accountability.

safety, effectiveness, efficiency, appropriateness

Canada does an excellent job in providing world-class acute care services, and we should; hospitals and physicians have been the core of our systems for decades. Now is the time to ensure sufficient resources are allocated to other elements of the continuum, including wellness and continuing care.

Home care is one readily available yet underused avenue for delivering health promotion and illness prevention initiatives and programs.

four critically important themes: dignity and respect, support for caregivers, funding and health human resources, and quality of care

Nadine Henningsen, Executive Director, Canadian Home Care Association

Today, an estimated 1.8 million Canadians receive publicly funded home care services annually, at an estimated cost of $5.8 billion. This actually only equates to about 4.3 per cent of our total public health care funding.

There are a number of initiatives within the home care sector that need to be addressed. Establishing a set of harmonized principles across Canada, accelerating the adoption of technology, optimizing health human resources, and integrated service delivery models all merit comment.

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

One was a reduction in chronic care services for the elderly and

a shift in the burden of costs for drugs and medical supplies to individual and families. This was due to early discharge and the fact that often a number of provinces do not cover the drugs and supplies under their publicly funded program.

Stakeholders across Canada generally agreed that the end-of-life expectations within the plan were largely met

How do we go from having a terrific acute care system to having maybe a slightly smaller acute care system but obviously look toward a chronic care system?

Across Canada, an estimated 30 to 50 per cent of ALC patients could and should benefit from home care services and be discharged from the hospital.

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

The return on investment for every dollar for home care is exponentially enhanced by the in-kind contribution of family caregivers.

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

a status report on hospice, palliative and end-of-life care in Canada

Dying for Care

inconsistent access to hospice palliative care services generally and also to respite care services; access to non-prescribed therapies, as well as prescription drug coverage

terminated by the federal government in March of 2008

the Canadian Strategy on Palliative and End-of-Life Care

Canadian Hospice Palliative Care Association and the Canadian Home Care Association embarked on what we called the Gold Standards Project

In 2008, the Quality End-of-Life Care Coalition released a progress report

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

Canadians should have the right to choose the settings of their choice. We need to look for a more seamless transition between settings.

In 2010, the Quality End-of-Life Care Coalition of Canada released its 10-year plan.

Seventy per cent of Canadians at this point in time do not have access to hospice palliative care

For short-term, acute home care services, there was a marked increase in the volume of services and the individuals served. There was also another benefit, namely, improved integration between home care and the acute care sector.

last summer, The Economist released a document that looked at palliative services across 40 countries

The second area in the blueprint for action is the support for family caregivers.

The increasing need for home-based care requires us to step up and strive for a comprehensive, coordinated and integrated approach to hospice palliative care and health care.

Canadian Caregiver Coalition

in Manitoba they have made great strides

In New Brunswick they have done some great things in support of family caregivers. Ontario is looking at it now.

we keep on treating, keep on treating, and we need to balance our systems between a curative system and a system that will actually give comfort to someone moving toward the end of their life

Both the Canadian Institute for Health Information and the Canadian Health Services Research Foundation have produced reports this year saying it is chronic disease management that needs our attention

When we look at the renewal of health care, we have to accept that the days of institutional care being the focus of our health care system have passed, and that there is now a third leg of the stool. That is community and home care.

Over 70 per cent of caregivers in Canada are women. They willingly take on this burden because they are good people; it is what they want to do. The patient wants to be in that setting, and it is better for them.

The Romanow report in 2002 suggested that $89.3 million be committed annually to palliative home care.

that never happened

What happened was a federal strategy on palliative and end-of-life care was announced in 2004, ran for five years and was terminated. At best it was never funded for more than $1.7 million.

Because our publicly funded focus has been on hospitals and one provider — physicians, for the most part — we have not considered how to bring the other pieces into the equation.

Just as one example, in the recent recession where there was special infrastructure funding available to stimulate the economy, the health system was not allowed to avail itself of that.

As part of the 10-year plan, first ministers agreed to provide first dollar coverage for certain home-care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care. It appears that health ministers were to report to first ministers on the implementation of that by 2006, but they never did.

One of the challenges we find with the integration of mental health services is

A lot of eligibility rules are built on physical assessment.

Very often a mental health diagnosis is overlooked, or when it is identified the home care providers do not have the skills and expertise to be able to manage it, hence it moves then over to the community mental health program.

in Saskatchewan it is a little more integrated

Senator Martin

I think ideally we would love to have the national strategies and programs, but just like with anything in Canada we are limited by the sheer geography, the rural-urban vast differences in need, and the specialized areas which have, in and of themselves, such intricate systems as well. The national picture is the ideal vision, but not always the most practical.

In the last federal budget we got a small amount of money that we have not started working with yet, it is just going to Treasury Board, it is $3 million. It is to actually look at how we integrate hospice palliative care into the health care system across all these domains.

The next 10-year plan is about integration, integration, integration.

the Canadian Patient Safety Institute, the Health Council of Canada, the Canadian Health Leadership Network, the health sciences centres, the Association of Canadian Academic Healthcare Organizations, the Canadian College of Health Leaders, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association, the Canadian Agency for Drugs and Technologies in Health and Accreditation Canada

We are all meeting on a regular basis to try to come up with our take on what the system needs to do next.

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

Have you done any costing or savings? Obviously, more home care means more savings to the system. Have you done anything on that?

In the last federal election, every political party had something for caregivers.

tax credits

the people we are talking about do not have the ability to take advantage of tax credits

We have a pan-Canadian health/human resource strategy in this country, and there is a federal-provincial-territorial committee that oversees this. However, it is insufficient

Until we can better collaborate on a pan-Canadian level on our human resources to efficiently look at the right mix and scope and make sure that we contain costs plus give the best possible provider services and health outcomes right across the country, we will have problems.

We have not as a country invested in hospital infrastructure, since we are talking about acute care settings, since the late 1960s. Admittedly, we are moving away from acute care centres into community and home care, but we still need our hospitals.

One of the challenges is with the early discharge of patients from the hospital. They are more complex. The care is more complex. We need to train our home support workers and our nurses to a higher level. There are many initiatives happening now to try to get some national training standards, particularly in the area of home support workers.

We have one hospital association left in this country in Ontario, OHA. Their CEO will constantly talk about how the best thing hospitals can do for themselves is keep people out of hospitals through prevention promotion or getting them appropriately to the next place they should be. Jack Kitts, who runs the Ottawa Hospital, and any of the CEOs who run hospitals understand one hundred per cent that the best thing they can do for Canadians and for their institutions is keep people out of them. That is a lot of the language.

We have an in-depth brief that details a lot of what is happening in Australia

I would suggest that it is a potentially slippery slope to compare to international models, because often the context is very different.

the Health Council told us, there remain “clear disparities in the availability of publicly-funded homecare across the country”

The Health Minister, ignoring the 80% of Canadians who want more home and community care added to the health system, has stated flatly that he is “not going to get involved” in home care because he sees it as a provincial matter.  As if to underscore his point, the government has dismantled the Secretariat set up in 2001 to coordinate the development of a national strategy on end-of-life care.

the government has been sitting on the report of the Wait Times Advisor for two full years.  Positive recommendations, including a more multidisciplinary approach and gender analysis, have been side-tracked. 

the federal government’s silence while for-profit forces have exploited public concern over wait times to resurrect their false promise of salvation through parallel for-profit care

after developing the Framework for Collaborative Pan-Canadian Health Human Resources Planning, the action plan so urgently needed has hit the doldrums

The Health Council has said planning remains “fragmented”

urgent need to address the health deficit faced by aboriginal Canadians with improvements to both health services and the determinants of health for aboriginal communities

Although the 10-year Plan includes health care in Northern communities and has incorporated the 2004 Blueprint for Aboriginal Health, the Health Council reports that “preventable health problems… continue to be of concern across the country”, and that “relatively little funding seems to have flowed”.

the federal government’s decentralized approach to national health care priorities has resulted in the loss of a national vision for health care and a directionless, leaderless renewal process at the national level

We recommend, therefore, that the federal government commit itself to a national, pan-Canadian, system-wide approach to public health care renewal anchored in Canada Health Act principles and enforcement, and with the jurisdictional flexibility and asymmetrical federalism found in the 10-Year Plan to Strengthen Health Care.

We recommend, therefore, that the government take urgent actions to get the Plan back on track in each of its areas of focus as quickly as possible, including: acting on the recommendations of the 2006 Interim Report of the National Pharmaceutical Strategy and the Report of the Wait Time Advisor; advancing the action plan under the Framework for Collaborative Pan-Canadian Health Human Resources Planning; energetically pursuing the objectives of the 2004 Blueprint for Aboriginal Health (most particularly where it relates to measures under direct federal jurisdiction); working with the provinces and territories to re-establish the Advisory Committee on Governance and Accountability as a functioning part of the renewal process; and convening a meeting of ministers of health to identify roadblocks that are impeding progress and to develop strategies to overcome these obstacles. 

the Canada Health Act, our main tool in protecting public health care, to which the 10-Year Plan to Strengthen Health Care is committed, is being undermined through inadequate monitoring and enforcement

The for-profit health industry continues to grow unabated

The Canada Health Act annual reports to Parliament do not reflect this due to their limited scope and the government’s failure to make improvements identified by the Auditor General back in 2002.

We recommend, therefore, that the Health Minister fully enforce the Canada Health Act by: setting data collection standards for reporting and enforcement that capture all for-profit activities that may impact on public health delivery; working collaboratively with the provinces and territories to fill gaps in reporting; stipulating that federal transfers should only be used for non-profit health care delivery; and removing any requirements that health infrastructure endeavours consider for-profit options such as public-private partnerships.

Mr. Rankin said that Ottawa should be working with the provinces, territories and municipalities to ensure they can provide an appropriate combination of services, treatment and support for those dealing with mental illness. He pointed to the national mental-health strategy developed by the Mental Health Commission of Canada in 2012 as a roadmap for improving services.

We would obviously want to look at each of those recommendations [in the strategy], but the general thrust of those recommendations, we would implement, absolutely," Mr. Rankin said. Among other points, the strategy calls for increased access to qualified psychotherapists and counsellors and the removal of financial barriers for children, youth and their families.

Mr. Rankin also called for a revival of the Health Council of Canada and a new federal health accord to foster communication between the federal government and the provinces on health. Both expired last year. Dr. Fry said the Liberals, if elected, would work closely with the provinces to develop a more integrated approach to health-care services, including mental health.

She said the last accord, which expired in 2014, had begun to look beyond the physician and the hospital and toward health care that could be provided by multidisciplinary teams. "We want to integrate mental health, in a fulsome way, into our health-care system," Dr. Fry said. "And that would mean a lot of the things that the Mental Health Commission talked about." However, she said the Liberals would not commit to specific actions before consulting with the provinces

We have to talk to the provinces about it," she said. "That's what we can commit to doing." Dr. Fry said a partnership between the federal government and the provinces on health care is necessary but declined to specify if a Liberal government would establish another health accord or bring in a different system. The length of the next partnership could also be up for discussion, she said.

Research suggests that psychotherapy, which is provided by a licensed therapist, is an effective treatment for many people struggling with anxiety and depression, the two most common psychiatric diagnoses. Therapy by private psychologists or social workers is not currently covered by any of the provinces. A spokesman for Health Minister Rona Ambrose said the provinces and territories are responsible for health-care delivery, including psychotherapy. The Conservative government created the Mental Health Commission of Canada and recently renewed its mandate for another 10-year period, he said.

A written statement from Ms. Ambrose, provided to The Globe and Mail, said the Canada Health Act does not preclude provinces and territories from extending public coverage to other services or providers such as psychologists. "Provinces and territories may choose to extend public coverage for such services," she said. With reports from Erin Anderssen in Ottawa This is part of a series about improving research, diagnosis and treatment

However, we should avoid diagnosing this problem merely as a failure of law enforcement. Murders represent the tip of an iceberg of problems related to endemic violence in communities. Many Aboriginal women and girls, and indeed men and boys, live each day under the threat of interpersonal violence and its myriad consequences.

Initial statements from the three federal ministers tasked with leading the forthcoming inquiry — the ministers of Indigenous and Northern Affairs, Justice and Status of Women — suggest that its purpose is to achieve justice, to renew trust between indigenous communities and the Canadian government and law enforcement bodies, and to start a process of healing.

The inquiry surely must also endeavour to lay the groundwork for a clear plan to address the broader problem of interpersonal violence, which, in turn, is rooted in several key determinants. Addressing interpersonal violence is not merely an issue of justice; it is also a public health concern.

Factors associated with both the experience and perpetration of interpersonal violence are manifold. They include but are not limited to mental health issues, drug and alcohol misuse, unemployment, social isolation, low income and a history of experiencing disrupted parenting and physical discipline as a child. The Truth and Reconciliation Commission’s report has highlighted that many of these factors are widespread in the Aboriginal populations of Canada.4 Many of the same factors contribute to disparities between Aboriginal and non-Aboriginal peoples in areas such as education, socioeconomic circumstances and justice. T

here is also substantial overlap with identified determinants of poor health in Aboriginal communities both in Canada and elsewhere.5,6 These are the factors associated with higher rates of youth suicide, adverse birth outcomes and tuberculosis, and poorer child health. It’s clear that a common web — woven of a legacy of colonization and cultural genocide, and a cumulative history of societal neglect, discrimination and injustice — underlies both endemic interpersonal violence and health disparities in Canada’s indigenous populations. There is no conversation to be had about one without a conversation about the other — if the aim is healing — because the root causes are the same.

The World Health Organization (WHO) is currently engaged in developing a global plan of action to strengthen the role of health systems in addressing interpersonal violence, particularly that involving women and girls.7 A draft report by the WHO acknowledges interpersonal violence as a strongly health-related issue that nevertheless requires a multisectoral response tailored to the specific context. Evidence from Aboriginal community models in Canada gives hope for healing.

A recent report from the Canadian Council on Social Determinants of Health highlighted important strides that some Aboriginal communities have made to address the root causes of, and to mitigate, inequities through efforts to restore the people’s connection with indigenous culture.8 Increasing community control over social, political and physical environments has been linked to improvements in health and health determinants.

The public health sector in many parts of Canada has embraced the need for strong community involvement in restoring Aboriginal people to the health that is their right. In many community-led projects over the past few decades, the health care sector has worked with others to address common proximal and distal determinants of disparities.

We are presented with not just an opportunity for renewing trust between indigenous communities and the Government of Canada but also for extending the roles of public health and the health care sector in the facilitation of trust and healing. There is much that the health sector can contribute to the forthcoming inquiry. Health Canada should be involved from the start to ensure that public health is properly represented

The health care system was in crisis. It took nearly 15 years of incremental increases to bring the federal portion of health funding back to the level is was at before Paul Martin took his axe to it. Going through an exercise like that again would be devastating for the health services that Canadians depend on each and every day.

Adding fuel to the speculation that the Liberals are planning massive cuts to health funding is Trudeau’s September 2nd letter to the Council of the Federation that makes no firm commitments to health care or federal transfers. The only firm commitment was to improve the federal-provincial relationship. That’s pretty thin gruel considering the state of that relationship after 10 years of Stephen Harper!

All Canadians who are concerned with the future of health care in this country need to scratch below Trudeau’s soothing words and take a look at his hard numbers. When you break down their plan, 77 per cent of the value of their “new investments” are tax shifts and benefits (including others not listed under that category), 12 per cent is the catch-all of ‘infrastructure’ spending (though most Canadians don’t think of early learning and cultural facilities as ‘infrastructure’), and five per cent is EI (paid for through EI premiums).

That leaves only six per cent, or a little over two billion a year for everything else. How much of that available funding will go to public home care and long-term care? How much will go to the provinces for new hospital beds after years of cuts? On reading the Liberal plan, we have to conclude: not a penny.

Their plan also targets $6.5 billion in spending reductions from an expenditure review. Will health care be on the table for cuts, if they can’t meet that ambitious target? John McCallum said on Saturday that in the effort to balance their books before the next election, ‘everything was on the table.’ Contrast this with Tom Mulcair’s plan for health care under a federal NDP government, and the stark choice is brought in to focus. 

Mulcair has committed to reversing Harper’s $36 billion in health care transfer cuts to the provinces.  He has committed to investing $5.4 billion into new public health care programs, including a prescription drugs, a plan for 41,000 home care and 5,000 long-term care spots. Over five million more Canadians will have access to primary health care through his plan to build 200 Community Health Clinics. And there are practical policy initiatives on mental health for youth, Alzheimer’s and dementia care.

Canadians cherish their universal Medicare system as one of the things that makes Canada great. They want a federal government that will commit the necessary funding and leadership to build the public health care system of our collective futures, to meet the challenges of an aging population and increasing drug costs. The next party to lead the federal government should be judged by the real dollars and focused policy it has committed to meet Canadians’ health care needs.

On that measure, the Liberal plan is dead on arrival. Paul Moist is national president of the Canadian Union of Public Employees. Representing over 633,000 members, including over 153,000 working in the health care sector, it is Canada’s largest union.

CIHR’s decision-making style, which resulted in it going ahead with changes to funding despite objections from Indigenous and non-Indigenous researchers, “is not consistent with the recommendations of the Truth and Reconciliation Commission,” says Rod McCormick, a Mohawk researcher and co-chair of the Aboriginal Health Research Steering Committee.

There is no recognition or provision for the fact that systemic policies, when applied across the board, can have damaging impacts for groups that are different,” McCormick told an emotionally charged meeting at the Wabano Centre for Aboriginal Health in Ottawa on Jan. 25.

In 2014/15, funding for Aboriginal health research was $31 million, down from $34 million at its annual peak 2004–2008, the Aboriginal Health Research Steering Committee reported.

McCormick and co-chair Frederic Wien, the principal investigator for the Atlantic Aboriginal Health Research Program, urged CIHR to revisit its changes and rebuild what Wien called “a respectful relationship with First Nations, Métis and Inuit people.” Given the crisis in the health and well-being of many of these communities, the researchers want CIHR to prioritize Aboriginal health research.

We have gone through major changes at CIHR. I do not deny that,” Beaudet said. “But I would deny ... that these changes are affecting particularly the Aboriginal community.”

Marlene Brant Castellano, co-director of research for the Royal Commission on Aboriginal Peoples, believes CIHR is out of step with the Truth and Reconciliation Commission’s recommendations.

Beaudet made the remarks just three days after the shootings at La Loche, Saskatchewan. The murder of two teenagers, a teacher and a teacher’s aide in the largely Dene community underscored for some attendees the crises in suicide, lack of mental health support and poverty that affect many Aboriginal youth and families.

Beaudet said Aboriginal health research is “extremely important” for CIHR, and its strategic investments will reflect that. CIHR has been working with the Aboriginal Health Research Steering Committee for 14 months and, according to the institute’s media specialist David Coulombe, is committed to “co-building research initiatives” that “will improve the health of Canada’s First Nations, Inuit and Métis peoples.”

While Beaudet acknowledged both the magnitude of the recent changes and the fact that the Aboriginal health research budget has “flatlined,” he said it has done so parallel to CIHR’s overall budget. CIHR’s billion-dollar annual federal budget has not increased since 2009, meaning that its spending power has declined by roughly 25% since then.

CIHR’s president denied any need for the federal agency to engage in reconciliation. “I would like to bring my personal views, not only those of CIHR, about the stormy weather we have been experiencing lately,” Dr. Alain Beaudet told attendees at the January meeting. “But not in the spirit of reconciliation, because I don’t think anything has been broken.”

The Aboriginal Health Research Steering Committee contends that CIHR disadvantages researchers working in Aboriginal health through recent changes such as scrapping an Aboriginal-specific peer review process, requiring matching funds for several granting programs, and reallocating almost half the open competition funding for stellar emerging and establishing scholars.

But Beaudet said the changes promote more “out-of-the-box” research that will enable Canada to achieve more international success. He also suggested that those critical of the new system are afraid of change, and advised researchers that “looking back doesn’t work.” Learning from the past is a critical Indigenous value. CIHR is starting to analyze the

results of its initial investments, but it will take seven years for the new system to take full effect and before “meaningful” figures result, Beaudet said. “We’ll work as quickly as we can, but we need the data. I’m saying ‘Yes, trust us,’ because if you look at CIHR’s record, we’ve done a lot, and we’ve done it in good faith.”

Most of the researchers and representatives of Aboriginal political organizations at the meeting did not seem inclined to trust Beaudet’s reassurances.

You’re really saying to this group, ‘Trust us.’ And I just want to remind you that there’s very little basis for trust,” said Scott Serson, a former deputy minister of Indian Affairs and Northern Development, now with Canadians for a New Partnership, a group working for a new relationship between Indigenous and other Canadians.

The Aboriginal Health Research Steering Committee asked CIHR to set aside half a day at the June meeting of its governing council to address these issues. In an online statement, Beaudet acknowledged the request for an in-depth discussion at “a future meeting” of the governing council. He also urged Indigenous health researchers and community members to apply as members of the new Institutes Advisory Board on Indigenous People’s Health and a new College of Reviewers.

Marlene Brant Castellano, co-director of research for the Royal Commission on Aboriginal Peoples and the Mohawk elder who closed the meeting, described Beaudet and CIHR’s response to the committee’s requests as “disconnected” from the prevailing political environment.

Castellano, who is revered as the first Aboriginal full professor at a Canadian university, brought many in the audience to tears. Instead of recognizing the need for a new relationship between Canada and its Indigenous peoples, Beaudet’s remarks echoed a too-familiar demand that Aboriginal researchers “get with” CIHR’s program because, eventually, they would discover it was good for them, Castellano said.

“We have 400 years as Indigenous people trying to make things work in other people’s agendas, and that is where we’ve gotten to the place now, where we still are, of watching our children dying,” she said, tears streaming down her cheeks.

Beaudet had already left the meeting before Castellano went to the podium, and the two CIHR vice-presidents who had stayed for most of the discussion left as she began to speak, citing prior commitments. Only Malcolm King, scientific director of CIHR’s Institute of Aboriginal Peoples’ Health and a member of the Mississaugas of the New Credit First Nation, remained for the duration of the meeting.

According to Coulombe, Beaudet had a phone conversation with Castellano on Jan. 29, and “agreed to continue working collaboratively with community representatives and leaders in the future.”

Dr. Brendon Carr (president and CEO of Island Health) when asked at the Island Health Board meeting here in June stated that there will be a premium in cost for the surgeries at the private clinic. We know private, for profit, health care is more expensive. He said they have the information and would provide it, but when I wrote and asked what the difference in cost for the taxpayers between surgeries in public or private, for profit, operating rooms, Mr. Peters declined to answer the question.

It is extremely concerning that our provincial government is contracting up to 55,000 surgeries to a private surgery clinic Re: Deal with private contractor could reduce surgery wait times - J.R. Rardon. The above noted article was in the Aug. 26, Campbell River Mirror. Reading the headline I have to ask "but at what cost?"

I pointed out to Dr. Carr that we have a shortage of doctors in Canada and he agreed. He said it would be the same doctors doing the surgeries in the private, for profit, surgery clinics. I asked how they can usurp our doctors into the private system without straining our public system more. He just said they will be watching it. That doesn't bode well for our public operating rooms. I fear that our provincial government is seriously undermining our position in defending the Dr. Brian Day court case on behalf of all British Columbians. At the very least it looks like a huge conflict of interest when they are seeking to contract an enormous number of surgeries to private clinics.

Our provincial and federal governments seem determined to starve the public health care system in favour of private, for profit, health care. They have let the surgery wait lists increase substantially. Our federal government refused to renegotiate the Canada Health Accord and brought in a new funding formula. They are telling us they are "increasing"  funding of the transfer payments to the provinces by three per cent, tied to the cost of living. Currently they are paying six per cent annually so this actually is a massive cut to the provinces for public health care in the amount of $36 billion over the next 10 years. With the federal government's cuts to health care funding, the share of federal CHT cash payments in provincial-territorial health spending will decrease substantially from 20.4 per cent in 2010-11 to less than 12 per cent over the next 25 years. This, according to the Parliamentary Budget Office, will bring the level of federal cash support for health care to historical lows. National Medicare was implemented across Canada by provinces and territories on the understanding that the federal government would contribute roughly 50 percent of the spending on Medicare.

Canadians are vehemently opposed to private health care whether it is using our public tax dollars or not. Canadians should not have to suffer and wait a long time for surgery. Funds would be far better invested in the public health care system which is being starved by our governments. It is very difficult for Canadians to see our medicare in serious jeopardy. The Canadian Medical Assoc., Canadian Doctors for Medicare, Canadian Health Coalition, Council of Canadians, B.C. Health Coalition, HEU, CUPE, Citizens for Quality Health Care and many others are united to protect, strengthen and expand our public health care. Please check out their websites and get more information. Please vote in the next two elections and vote for health care for the benefit of all Canadians. Lois Jarvis Citizens for Quality Health Care Campbell River

In its final major report, Better Health, Better Care, Better Value for All, the health council described the years of the Canada Health Accord as a decade of failing Canadians. This is strong language, and perhaps the council was emboldened by its impending closure. Still, it's hard to argue with the sentiment in the light of overall health spending in this country.

Now we see the federal government making a bad situation worse by walking away from the process of rebuilding a national health system entirely instead of negotiating a more robust agreement with targets and timelines for innovation and cost-savings.

Ryan Meili is an expert adviser with EvidenceNetwork.ca, assistant professor in the Department of Community Health and Epidemiology at the College of Medicine, University of Saskatchewan, and a family doctor. (Troy Media, troymedia.com).

We need to stabilize the situation in Attawapiskat in terms of making sure they have the health support they need,” Mr. Angus (Timmins-James-Bay, Ont.) told The Hill Times last week. “We need a plan to get people who are needing help in any of the communities to get that help.”

A rash of attempted suicides prompted Mr. Angus, who’s also the NDP critic for indigenous and northern affairs, to call for an emergency debate on the ongoing suicide crisis in the James Bay community of about 2,000. As a result, the House of Commons convened until midnight last Tuesday for an emotionally charged discussion on mental health services following a string of incidents in northern reserves in recent months. Several MPs choked up during their statements, recounting suicide incidents in their ridings and personal lives.

Sometimes partisan politics need to be put aside and members need to come together to find solutions to prevent another unnecessary loss of life,” Conservative MP Todd Doherty (Cariboo-Prince George, B.C.) said during the debate. NDP MP Georgina Jolibois (Desnethé-Missinippi-Churchill River, Sask.) said the suicide rate went up in her home community of La Loche in northern Saskatchewan after a shooting spree that killed four people last January.

Liberal MP Robert-Falcon Ouellette (Winnipeg Centre, Man.) recalled visiting the northern Manitoba Pimicikamak Cree Nation, which declared a state of emergency over a series of suicide attempts last month.

Mr. Angus made an emotional appeal to action in his opening remarks during the emergency debate. “We have to end the culture of deniability whereby children and young people are denied mental health services on a routine basis, as a matter of course, by the federal government,” he said. Eleven people attempted to take their lives in Attawapiskat two Saturdays ago, prompting the First Nation to declare a state of emergency—the fourth one since 2006. There has been more than 100 suicide attempts in the reserve since the month of September, many of which involved children. The community has been plagued by flooding and several housing crises in recent years.

Eighteen mental health workers were dispatched to Attawapiskat on Tuesday, including two counsellors, one crisis worker, two youth support workers, and one psychologist. While there is no set timeline, they’re not expected to leave for at least two weeks, said Health Canada assistant deputy minister Keith Conn during a teleconference last week.

Some of the people treated for mental health problems last week had previously been airlifted out of the community for assessment before being sent back after their examination, according to Mr. Conn. This past Tuesday, at least 13 people, including a nine-year-old child, had made plans to overdose on prescription pills as part of a suicide pact. The Nishnawbe-Aski Police Service apprehended them before sending them to the local hospital for a mental health assessment.

Mr. Conn said he’s heard criticism of the mental health assessment process from Attawapiskat First Nation Chief Bruce Shisheesh. Individuals who are identified as likely to commit suicide are typically sent to a hospital in Moose Factory, Ont., to be psychologically evaluated by a psychologist or psychiatrist. They are then discharged and sent back to the community, where some try to take their life again. Mr. Conn said Health Canada does not “control the process,” but he personally committed to review the mental health assessment effectiveness.

No federally funded psychiatrists were present in the region prior to the crisis, despite reserve health-care falling under the purview of the federal government. Mr. Conn said the Weeneebayko Area Health Authority (WAHA), a provincial health unit servicing communities on the James Bay coastline, is usually responsible for the Attawapiskat First Nation following an agreement struck with the federal government about 10 years ago.

A mental health worker position for the reserve has been vacant since last summer, in part because there’s a lack of housing for such staff. The community has been left without permanent, on-site mental health care services. Since then, the position has been filled by someone already living on reserve. During the emergency debate in the House last week, Health Minister Jane Philpott (Markham-Stouffville, Ont.) emphasized the need for short- and long-term responses to the crisis.

We need to address the socio-economic conditions that will improve indigenous people’s wellness in addition to ensuring that First Nations and Inuit have the health care they need and deserve,” she said. Ms. Philpott pointed to the Liberal government’s budget, which includes $8.4-billion for “better schools and housing, cleaner water, and improvements for nursing stations.”

“Our department and our government are ensuring that all the necessary services and programs are in place,” she said during the debate. “We are currently investing over $300-million per year in mental wellness programs in these communities.” Yet, Mr. Angus said the budget includes “no new mental health dollars” for First Nations communities. In addition to allocating more funds for mental health services to indigenous communities, Mr. Angus said there needs to be a concerted effort to bring in the aboriginal youth in the conversation.

We need to bring a special youth council together,” he told The Hill Times on Wednesday. “We need to have them be able to come and talk to Parliament about their concerns, so we’re looking at those options now.” Emotion was audible in Mr. Angus’ voice when he read letters he received from Aboriginal youth during the emergency debate, which expressed a desire to work with the federal government to solve the crisis.

The greatest resource we have in this country is not the gold and it is not the oil; it is the children,” he said. “The day we recognize that is the day that we will be the nation we were meant to be.” Mr. Angus met with Indigenous and Northern Affairs Minister Carolyn Bennett (Toronto—St. Paul’s, Ont.) earlier in the week to discuss potential long-term solutions to the suicide crisis. “I’ve always had an excellent relationship with Carolyn Bennett, and as minister we’re trying to find ways to work together on this, to take the tension down, to start finding solutions,” Mr. Angus said. Mr. Angus criticized “Band-Aid” solutions that have been thrown at First Nations issues over the years and said there needs to be a “transformative change” this time.

That’s where we have to move beyond the positive language to actually the brass tacks,” he said. During the emergency debate, Mr. Angus supported the idea of giving more resources to frontline workers such as on-reserve police, and health and treatment centres. 0eMr. Angus’ riding sprawls from shores of the Hudson Bay to the Timiskaming district on the border with Quebec, an area roughly equivalent in land size to that of Guinea. He holds two constituency offices in Timmins and Kirkland Lake.

The federal government has made a start with the creation of the Employer Panel for Caregivers and the Family Caregiver Tax Credit. However, it must do more to make a meaningful difference in the lives of Canadians caring for family members. For example, making the caregiver tax credit refundable would help mitigate care costs such as paying out of pocket for prescriptions, groceries and personal care items or taking time off work for medical appointments. Until all levels of government come together to form a comprehensive pan-Canadian seniors strategy, piecemeal initiatives will have a limited impact.

In a way, our generation has become a victim of our own success. Progress and innovation in medicine mean Canadians are living longer. At the same time, more people are living with chronic diseases that complicate both their health status and the treatment they need. Treatment of chronic diseases consumes 67 per cent of all direct health-care costs. Chronic disease is the main reason seniors require health care. In 2011, between 74 and 90 per cent of Canada's seniors suffered from at least one chronic condition, while nearly one-quarter had two or more. These conditions jeopardize a person's ability to live independently at home.

On any given day in Canada, "alternative level of care" patients - that is, patients approved for hospital discharge who cannot access appropriate post-hospital care - occupy about 7,500 beds. Hospitals are routinely forced into a state of overcapacity called "code gridlock" in which patient flow grinds to a halt, elective surgeries are cancelled and transfers are put on hold. If you are in a car accident or have a heart attack, our health-care system can effectively mobilize world-class acute health-care services. But the system is woefully inadequate and under-resourced to properly prevent, manage or treat the long-term and chronic health problems facing most of our over 65 population.

Too often, seniors who could and should be getting better are languishing in hospitals when more efficient and effective care could be delivered in their homes or in a long-term care facility. It costs $1,000 to keep a person in a hospital bed for a day. Long-term care costs $130 a day. Home care (excluding the economic costs of caregivers looking after relatives) costs $55. That translates to approximately $2.3 billion a year that could be better spent in the health-care system with some strategic thinking and investing. This country as we know it today was, in fact, built by our seniors - by our own mothers and fathers, aunts and uncles and grandparents. Canada's health-care providers are determined and committed to prioritizing and improving their health. We expect the same of our country's leaders. As the premiers gather just blocks from Parliament Hill, we ask that a comprehensive healthy aging and seniors care strategy be at the top of their agenda.

Christopher Simpson, MD, is president of the Canadian Medical Association. Morel Caissie is president of the Canadian Association of Social Workers. Karima Velji is president of the Canadian Nurses Association.

"The problems we found is the private sector genuinely believe they will be more efficient and when they discover they can't be much more efficient than our National Health Service, or for that matter, your public health services here, they have to start cutting back on standards and in quite a number of cases now in Britain, they've taken over a franchise (clinic) and can't make a go of it, so then hand it back because they can't cope with actually running a decent service," Dobson said. He also said that drawing up contracts with private clinics is complicated and costly. "The people creating the contract try to cover every eventuality in the contract, and they need to do that because in Britain we had a case where a woman had a major hemorrhage in a small hospital and they didn't have an emergency blood supply, so they sent someone to the nearest NHS hospital to get some blood.

"By the time they got back, the woman had bleed out and died. When (officials of private clinic) were pressed about this, they said, 'Oh well, it didn't specify in the contract that we had to have an emergency blood supply,'" Dobson said. He said the contracts "have to be water tight, and it means legions of lawyers, accountants and management consultants" drawing up contracts and "that is money that is not going" into patient care.

Kevin Cook, of OCHU, who is travelling with Dobson, said that the Canadian Union of Public Employees and OCHU oppose the Ontario government's plans to expand the use of private specialty clinics to deliver services currently being provided by local hospitals. "First of all, this isn't about the job losses (with our members), this is about patient safety and the patients come first," Cook said. "We are concerned with infection control issues" ... there are different measures in hospitals then there are in private clinics. Hospitals have an infection control team, they have the department that cleans the instruments, then it goes to the doctor, so there is a different chain within the private clinics.

"They are not going to have the same standards" as a hospital, Cook said. Cook gave an example of how things can go wrong in a private clinic. In September 2007, a patient bled to death undergoing liposuction surgery at a private clinic in Ontario. The tragedy happened a few months after Dobson visited Ontario and cautioned the provincial government on allowing private surgery and procedure clinics to open in Ontario. "We are asking the Ontario government to stop the private clinics. It is not cheaper; it will cost us in the long run. And they keep saying it is a savings, but it is not," Cook said.

Dobson agreed. "The thing I try to get across is this ... everyone in Canada knows that you spend, roughly speaking, half as much as the Americans spend in their health-care system. So the idea that a competitive system like theirs is cheaper, doesn't make a lot of senses. And it also means that the private sector is trying to come in and take over what is essentially in Canada and Britain, a very, very, cost-effective health-care system. "Always remember, with private businesses, their primary duty is to provide their shareholders with profit," Dobson said. sud.editorial@sunmedia.ca

Frank Dobson, right, a former health minister in the United Kingdom, spoke to reporters about the pitfalls of private clinics during a visit to Sudbury on Tuesday. Looking on is Kevin Cook, of the Ontario Council of Hospital Unions.

The gestures stem not only from the country's growing diversity, but a generally more patient-focused system - and a recognition treating solely physical ailments is not always enough. "If we don't engage in the (cultural) discussion, we won't fully understand their health needs and they won't get met," says Marie Serdynska, who heads a pioneering project in the field, the Montreal Children's Hospital's socio-cultural consultation and interpretation services.

So ultimately they will get sicker and be a greater cost to the health-care system." But with the topic being featured at national pediatric and bioethics conferences recently, medical professionals are debating a difficult question: is there is a point at which catering to cultural preferences crosses a moral - or even legal - line? While a physician in the neonatal intensive care unit at Toronto's SickKids hospital, Dr. Jonathan Hellman was sometimes asked by fathers from "patriarchal" cultures not to discuss a child's condition with the mother unless the husband was also present.

Agreeing to such a request not only raises ethical and practical questions, he says, but might even violate Ontario's Health-Care Consent Act - unless the mother explicitly agreed to the arrangement. "It's challenging to the caregivers in that situation, when the mother is at the bedside and the father is able to visit only in the evenings," says Hellman. "And we believe that both equally have decision-making power, both should have information." Even hospitals that try to be sensitive to specific cultural groups, like Ontario's Hamilton Health Sciences Centre, with its aboriginal patient "navigator," can face vexing dilemmas. When two First Nations girls with leukemia decided to withdraw from chemotherapy at the facility and try native remedies, an emotional courtroom battle followed.

And it recently emerged that a Vancouver-area intensive-care unit was asked to keep a braindead patient on life support for days until he could be flown to his country of origin, the family's culture rejecting the concept of neurological death. Still, for every demanding request, there are dozens of positive incidents - even if they involve once-unheard-of accommodation, say ethicists, doctors and patient advocates.

Some Halifax hospitals have convinced the fire marshal to allow smudging, aboriginal purification rituals in which sweetgrass is burned. Sometimes, this means adjusting the smoke detector in a patient's room temporarily so it doesn't set off an alarm, says Christy Simpson, a bioethicist at Dalhousie University in Halifax. Randi Zlotnik Shaul, director of bioethics at SickKids, said she's aware of a request for a drumming circle in a neonatal intensive care unit, a normally very quiet environment. Steps were taken to comply with the proposal - and not interfere with other tiny patients - but the need for an open fire eventually made it impossible, she said.

Yet fulfilling such appeals, often made for dying patients, can be a question simply of innovation and compromise, like when someone asks that a patient's bed face Mecca, she says. "Some might respond very categorically, 'Nope, in this place all beds face the same way,' "she says. "Someone oriented another way might say, 'Yeah, they are all faced that way, but maybe if we got an extension cord, there is actually something we can do.' " Serdynska says she knows of hospitals providing "mementos" of births to new mothers whose cultures traditionally require them to bury their placenta. Dr. Tara Kiran, a Toronto family physician, was taken aback when she first encountered patients from Bangladesh and Pakistan at an inner-city clinic who insisted on fasting between sunrise and sunset during Ramadan, despite health issues like diabetes that normally require strict regulation of diet and medication.

Her patients, however, happily embraced what they saw as the experience's beneficial, spiritual benefits. "It was an interesting challenge to my assumptions," says Kiran. "My gut reaction was that fasting has negative impacts on health." In London, Ont., St. Joseph's Health Centre runs a special clinic during Ramadan to help the city's estimated 3,000 diabetic Muslims. Muslim needs, including heightened privacy for female hospital patients instead of the usual, unannounced arrival of staff at the bedside, were once given short shrift, says Khadija Haffajee, spokeswoman for the National Council of Canadian Muslims. But the system has generally made great strides, adds Haffajee, who has addressed classes of nursing students on her faith's practices. "It's about reasonable accommodation and understanding," she says. "When people are ill, you're dealing with very vulnerable people, so empathy goes a long way."

Accommodation can sometimes simply be a case of bridging the cultural divide, says Montreal's Serdynska. Medical teams at her hospital once saw Vietnamese patients with unexplained bruising and immediately suspected child abuse. Further inquiry revealed the marks were the result of "capping," or "coining," a traditional southeast Asian treatment that involves scraping a smooth edge across the body in the belief it releases unhealthy elements. Her service now has cultural interpreters who will talk to immigrant parents when, for instance, drug treatment is not working. Sometimes, it relates to the side effects and contraindications spelled out on unfamiliar packaging, she says. "For some cultures who do not generally take pharmaceutical medication, this is very frightening." The institutional, impersonal nature of a hospital alone makes it a daunting place for aboriginal people, especially if they attended residential schools, says Margo Greenwood, academic leader at the National Collaborating Centre for Aboriginal Health in Prince George, B.C. Hanging indigenous art, providing culturally appropriate prayer space and consulting local native communities all help alleviate that anxiety, as does being open to other forms of treatment.

You're dealing with two different systems of knowledge: one is what I learned when I went to university and one is what I learned in my community," she says. "People (are) saying ... 'I want the two to work together.' "But what are health-care providers to do when the request stemming from an ethnic or religious practice appears to breach their own ethical boundaries? Reports in 2013 of doctors in Quebec issuing virginity certificates earned a swift response from the province's medical regulatory body. Physicians must refuse to comply, insisted the College des Médecins, and explain such a service has nothing to do with health care. Less black-and-white, perhaps, is the patient asking for a doctor of a particular sex or, less commonly, of a specific race. On the surface, at least, the idea is a repudiation of fundamental human-rights principles, yet for some patients it could be a religious imperative or a fallout from past abuse.

Some hospitals say they will try as much as possible to provide a female doctor for Muslim women, for instance, when asked. In Montreal, about half the obstetrician-gynecologists are women, so supplying a female one is usually quite feasible, said Togas Tulandi, interim head of the McGill University medical school's obstetrics and gynecology department. More troublesome, say ethicists and physicians, are patients who insist they not be treated by a doctor or nurse of a certain race - typically Caucasians rejecting non-white workers in today's multi-hued medical workforce - or want one of their own colour. Ethicists at Toronto's University Health Network (UHN) published a nine-page paper on how to tackle "discriminatory" requests of this sort, suggesting the affected health-care worker should often have the final say.

"It's ugly, it's unfair," says Linda Wright, a bioethicist at UHN, of the potential impact on medical staff. "To ... have someone say you're not good enough because of the colour of your skin is offensive." How often Canadian hospitals have to deal with the dilemma is unclear. A 2010 U.S. study of emergency doctors, though, concluded the scenario is common, with hospitals frequently accommodating requests for race-specific practitioners. And that is not such a bad thing, argued U.S. law professor Kimani Paul-Emile in a provocative 2012 article. He cited evidence that having a "race-concordant" doctor can bring health benefits, especially for blacks and others who have historically faced prejudice. In the meantime, hospitals here are still more likely to encounter less-contentious culturally based issues, such as whether to loosen age-old restrictions on the number of well-wishers in a patient's room.

"In some cultures ... you have everybody there. You have all the aunts and all the uncles, and all the family members and friends," says Dalhousie's Simpson. "For me, that's been one of the really interesting changes. Why did we say it only had to be two? Why did we limit it so much? Because clearly there's value to having your loved ones around you."